Alcohol-Related Emergency Alcohol-Related Emergency Department Visits in the Department Visits in the

United StatesUnited StatesCenter to Prevent Alcohol ProblemsCenter to Prevent Alcohol Problems

Boston University School of Public HealthBoston University School of Public HealthRalph Hingson, ScDRalph Hingson, ScDMichael Winter, MPHMichael Winter, MPH

American Public Health AssociationAmerican Public Health AssociationAnnual MeetingAnnual MeetingWashington, DCWashington, DC

November 10, 2004November 10, 2004

GentilelloBrief Motivational Alcohol Intervention in a

Trauma Center; Annals of Surgery, 1999

46% of injured trauma center patients 46% of injured trauma center patients age 18 and older screened positive for age 18 and older screened positive for alcohol problems.alcohol problems.

Half (N=336) randomly allocated to Half (N=336) randomly allocated to receive 30 minute brief intervention to receive 30 minute brief intervention to reduce risky drinking and offered links reduce risky drinking and offered links to alcohol treatmentto alcohol treatment

GentilelloGentilelloBrief Motivational Alcohol Intervention in a Brief Motivational Alcohol Intervention in a

Trauma Center; Trauma Center; Annals of SurgeryAnnals of Surgery, 1999, 1999

Reduced alcohol consumption by an average Reduced alcohol consumption by an average 21 drinks per week at 1 year follow up21 drinks per week at 1 year follow up

47% reduction in new injuries requiring 47% reduction in new injuries requiring treatment in EDtreatment in ED

48% reduction in hospital admissions for 48% reduction in hospital admissions for injury over 3 yearsinjury over 3 years

23% fewer drunk driving arrests23% fewer drunk driving arrests

MontiMontiBrief Intervention For Harm Reduction with Brief Intervention For Harm Reduction with

Alcohol Positive Older Adolescents in a Alcohol Positive Older Adolescents in a Hospital Emergency Department, Hospital Emergency Department,

J. Consulting and Clinical PsychologyJ. Consulting and Clinical Psychology

94 ED patients, mean age 18.4, injured after drinking94 ED patients, mean age 18.4, injured after drinking

Half randomly allocated to a 35-40 minute motivational Half randomly allocated to a 35-40 minute motivational intervention to reduce drinking and related risky intervention to reduce drinking and related risky behaviors such as DWIbehaviors such as DWI

89% followed at 6 months, no difference between 89% followed at 6 months, no difference between groups:groups:– Follow up rateFollow up rate– AgeAge– gendergender

Monti et al., 1999Monti et al., 1999Results at 6 monthsResults at 6 months

MIMI SCSC

Drinking and Drinking and drivingdriving

62%62% 85%85% SC had 4 times SC had 4 times more drinking and more drinking and driving occasionsdriving occasions

Moving ViolationsMoving Violations 3%3% 23%23%

Alcohol-related Alcohol-related injuryinjury

21%21% 50%50% SC had 4 times SC had 4 times more alcohol-related more alcohol-related injuryinjury

Other alcohol-Other alcohol-related problemsrelated problems

M=.88M=.88 1.451.45

Comparable drinking declines in both groups

Longabaugh (2001)Longabaugh (2001)

539 Injured Emergency Department Patients

Brief Intervention (BI)

Brief Intervention and Booster (BIB)

Standard Care (SC)

R

J. Studies on Alcohol. 62: 806-816

Longabaugh 2001Longabaugh 2001Brief InterventionBrief Intervention

40-60 minutes (based on Motivational 40-60 minutes (based on Motivational Enhancement Intervention in Project MATCH)Enhancement Intervention in Project MATCH)

Patients queried about the connection between Patients queried about the connection between drinking and their injurydrinking and their injury

Patients drinking compared to National SamplePatients drinking compared to National Sample

Financial cost of drinkers and negative Financial cost of drinkers and negative consequences assessedconsequences assessed

Work plan to reduce drinking developed (if goal Work plan to reduce drinking developed (if goal of patient)of patient)

Longabaugh 2001Longabaugh 2001

Booster SessionBooster Session

7 days after Brief Intervention7 days after Brief Intervention

Discussed post discharge drinking and Discussed post discharge drinking and experiencesexperiences

Results: Longabaugh 2001Results: Longabaugh 2001

Standard care (SC) 6% decline in alcohol related Standard care (SC) 6% decline in alcohol related injuriesinjuriesBIB 36% decline in alcohol related injuries than BIB 36% decline in alcohol related injuries than standard carestandard careNo differences BI and SCNo differences BI and SC– Negative drinking consequencesNegative drinking consequences– Number of heavy drinking daysNumber of heavy drinking days– InjuriesInjuries

Number of heavy drinking days similar in all 3 Number of heavy drinking days similar in all 3 groups at follow upgroups at follow up

Recent studies showing positive benefits of screening and brief interventionCrawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Reece B, Brown A, Henry JA. Screening and referral for brief Reece B, Brown A, Henry JA. Screening and referral for brief intervention of alcohol-misusing patients in an emergency intervention of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial. Lancet. 2004 department: a pragmatic randomised controlled trial. Lancet. 2004 Oct 9;364(9442):1334-9.Oct 9;364(9442):1334-9.

Spirito A, Monti PM, Barnett NP, Colby SM, Sindelar H, Rohsenow DJ, Spirito A, Monti PM, Barnett NP, Colby SM, Sindelar H, Rohsenow DJ, Lewander W, Myers M. A randomized clinical trial of a brief Lewander W, Myers M. A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in motivational intervention for alcohol-positive adolescents treated in an emergency department. J Pediatr. 2004 Sep;145(3):396-402.an emergency department. J Pediatr. 2004 Sep;145(3):396-402.

Dill PL, Wells-Parker E, Soderstrom CA. The emergency care setting Dill PL, Wells-Parker E, Soderstrom CA. The emergency care setting for screening and intervention for alcohol use problems among for screening and intervention for alcohol use problems among injured and high-risk drivers: a review. Traffic Inj. Prev. 2004 injured and high-risk drivers: a review. Traffic Inj. Prev. 2004 Sep;5(3):278-91. Review.Sep;5(3):278-91. Review.

Whitlock EP, Polen MR, Green CA, Orleans T, Klein J; U.S. Preventive Whitlock EP, Polen MR, Green CA, Orleans T, Klein J; U.S. Preventive Services Task Force. Behavioral counseling interventions in primary Services Task Force. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004 Apr 6;140(7):557- 68. Review2004 Apr 6;140(7):557- 68. Review

PurposePurpose

To determine how many emergency department To determine how many emergency department visits annually in the U.S. are:visits annually in the U.S. are:– Alcohol RelatedAlcohol Related– Alcohol related injuriesAlcohol related injuries

To determine To determine – What proportion of persons admitted to emergency What proportion of persons admitted to emergency

departments for alcohol related problems are referred departments for alcohol related problems are referred to additional alcohol treatmentto additional alcohol treatment

– Whether likelihood of referral varies by injury severityWhether likelihood of referral varies by injury severity

MethodsMethods

National Hospital Ambulatory Care Survey National Hospital Ambulatory Care Survey January 1-December 31, 2001January 1-December 31, 2001– Hospitals in the 2000 SMC Hospital Data Base (50 Hospitals in the 2000 SMC Hospital Data Base (50

added in 2001 new or changed eligibility)added in 2001 new or changed eligibility)– 4 stage Probability Sampling. Primary Sampling Units 4 stage Probability Sampling. Primary Sampling Units

(PSUs) 479 Hospitals within PSUs. 395 EDs within (PSUs) 479 Hospitals within PSUs. 395 EDs within Hospitals and/or clinics within obligated departments.Hospitals and/or clinics within obligated departments.

– 90% ED participation90% ED participation– 85% Visit response rate85% Visit response rate

N=34, 546 completed patient record formsN=34, 546 completed patient record forms

ResultsResults

2001 107.5 million ED visits2001 107.5 million ED visits

2.5 million alcohol related ED visits (2%)2.5 million alcohol related ED visits (2%)

39.4 million injury/poisoning visits 39.4 million injury/poisoning visits 5% alcohol related N= 2 million5% alcohol related N= 2 million

ResultsResults

94,589,648 first time visits94,589,648 first time visits

2,162,807 alcohol related (2%)2,162,807 alcohol related (2%)

35,358,989 Injury related35,358,989 Injury related5% alcohol related N= 1,860,8145% alcohol related N= 1,860,814

Results: 1Results: 1stst Time Admissions Time Admissions

86% treated and discharged 86% treated and discharged 2% alcohol related N= 1,712,5982% alcohol related N= 1,712,598

<1% held for 23 hours observation (544,541)<1% held for 23 hours observation (544,541)3% alcohol related N= 18,9683% alcohol related N= 18,968

11% admitted to hospital (10,848,702)11% admitted to hospital (10,848,702)3% alcohol related N= 362,2803% alcohol related N= 362,280

1% admitted to ICU/CCU (973,733)1% admitted to ICU/CCU (973,733)6% alcohol related N= 53,9846% alcohol related N= 53,984

0.2% died (228,689)0.2% died (228,689)6% alcohol related N= 14,8026% alcohol related N= 14,802

ResultsResults

Among ED alcohol related patients not observed Among ED alcohol related patients not observed or admitted to the Hospital ICU/CCU, 14.9% or admitted to the Hospital ICU/CCU, 14.9% were referred to additional alcohol treatmentwere referred to additional alcohol treatmentAmong ED alcohol related injury patients Among ED alcohol related injury patients observed, only 3% were referred to alcohol or observed, only 3% were referred to alcohol or drug treatmentdrug treatmentAmong ED alcohol related injury visits Among ED alcohol related injury visits hospitalized, only 2% (N=6,297) were referred hospitalized, only 2% (N=6,297) were referred for additional alcohol treatment for additional alcohol treatment Among ED alcohol related injury visits admitted Among ED alcohol related injury visits admitted to ICU/CCU none were referred to additional to ICU/CCU none were referred to additional alcohol treatmentalcohol treatment

ConclusionConclusion

The more serious the injury the greater the The more serious the injury the greater the percentage that were alcohol relatedpercentage that were alcohol related

The less serious the alcohol-related injury, The less serious the alcohol-related injury, the greater the likelihood the patient would the greater the likelihood the patient would be referred for alcohol treatmentbe referred for alcohol treatment

DiscussionDiscussion

McDonald, Wang, Camarge. McDonald, Wang, Camarge. Archives of Internal MedicineArchives of Internal Medicine. . 1643: 531-537, 20041643: 531-537, 2004Examined 2000 National Hospital Ambulatory Care Examined 2000 National Hospital Ambulatory Care SurveySurveyAssigned Alcohol Attributable Fractions to 37 diagnoses Assigned Alcohol Attributable Fractions to 37 diagnoses at admission (AAF)at admission (AAF)AAF was calculated based on extensive review of clinical AAF was calculated based on extensive review of clinical case series, injury surveillance studies available case series, injury surveillance studies available epidemiologic studiesepidemiologic studiesAAF represents the proportion disease cases, deaths or AAF represents the proportion disease cases, deaths or injuries causally linked to alcohol misuseinjuries causally linked to alcohol misuseEach of the 37 diagnosis multiplied by the number of ED Each of the 37 diagnosis multiplied by the number of ED visits for each diagnosisvisits for each diagnosis

3 Groups of AAF’s3 Groups of AAF’s

1.1. 100% attributable to alcohol by alcohol 100% attributable to alcohol by alcohol dependence alcoholic cirrhosisdependence alcoholic cirrhosis

2.2. AAF <1 disease e.g. oral cancer 50%AAF <1 disease e.g. oral cancer 50%

3.3. AAF <1 injuries e.g. motor vehicle AAF <1 injuries e.g. motor vehicle injuries 42%injuries 42%

Key FindingsKey Findings

Instead of 2.2 million alcohol related ED Instead of 2.2 million alcohol related ED visits they estimated there are 8.4 million visits they estimated there are 8.4 million alcohol related visitsalcohol related visits

Only 20% of patients with 100% alcohol Only 20% of patients with 100% alcohol attributable conditions were admitted to attributable conditions were admitted to hospitals meaning many are discharged hospitals meaning many are discharged without alcohol treatmentwithout alcohol treatment

DiscussionDiscussion

Emergency Departments or Trauma Centers Emergency Departments or Trauma Centers should screen all patients for alcoholshould screen all patients for alcoholAlcohol related ED admissions offer a teachable Alcohol related ED admissions offer a teachable moment for successful brief interventionmoment for successful brief intervention35 states have laws allowing insurance 35 states have laws allowing insurance companies to deny medical reimbursement for companies to deny medical reimbursement for treating patients injured under the influencetreating patients injured under the influenceThese laws should be repealed and the effects These laws should be repealed and the effects on the proportions of patients screened and on the proportions of patients screened and offered brief intervention for alcohol should be offered brief intervention for alcohol should be monitoredmonitored